Medical Director – Medicare Pharmacy

Humana

. Review Medicare Part D and Part B drug appeals .

Posted 10/30/2026part-timeRemote • United StatesLead💰 $223,800 - $313,100 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Medicare Part D and Part B drug appeals, applying CMS policies and clinical guidelines to optimize value-based care. Possesses strong analytical skills and a commitment to quality management within the managed care industry.

Highest-signal resume keywords

MD Or DO DegreeCurrent And Unrestricted LicenseBoard Certification In Internal Medicine, Family Medicine, Emergency Medicine, Or Physical Medicine And RehabilitationUtilization Management Experience5+ Years Of Direct Clinical Patient Care Experience

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Medicare Part D Appeals ReviewClinical AnalysisUtilization ManagementQuality ManagementKnowledge Of National GuidelinesAnalytic And Interpretation SkillsComputer-Based Coverage ReviewsExposure To Public Health And Population HealthBusiness Metrics UtilizationClinical Patient Care

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationTeam Collaboration

Tools & Technologies

MCGInterQualNCCNMicromedexLexicompElsevier's Clinical Pharmacology

Certifications & Qualifications

Board Certification

Industry Keywords

Managed Care IndustryIntegrated Delivery SystemsHealth InsuranceClinical Group Practice ManagementMedicare AdvantageManaged MedicaidClinical GuidelinesCMS PoliciesNational And Local Coverage DeterminationsPHI/HIPAA Compliance

About the role

Key responsibilities & impact

Review Medicare Part D and Part B drug appeals
Analyze moderately complex to complex cases using Medicare rules, Humana policies, and medical necessity criteria
Collaborate with clinicians and support staff to provide Humana members with optimal value-based care
Apply CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature
Learn Medicare Part D and Medicare Advantage requirements and operationalize them in daily work
Conduct computer-based coverage reviews for drug appeals
Use inter- and intra-departmental resources
Perform other responsibilities as necessary to support value-based care in accordance with Medicare and Humana policy
Travel occasionally to Humana offices for training or meetings

Requirements

What you’ll need

MD or DO degree
A current and unrestricted license in at least one jurisdiction and willingness to obtain additional license, if required
Current and ongoing Board Certification, with preference for Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation
No current sanction from Federal or State Governmental organizations
Able to pass credentialing requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills
Prior experience participating in teams focusing on quality management, utilization management, or similar activities
Knowledge of the managed care industry, Integrated Delivery Systems, health insurance, or clinical group practice management
Utilization management experience in a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial health insurance
5+ years of direct clinical patient care experience post residency or fellowship, preferably including experience related to a Medicare-type population
Experience with national guidelines such as MCG, InterQual, NCCN, Micromedex, Lexicomp, and Elsevier's Clinical Pharmacology
Exposure to Public Health, Population Health, analytics, and use of business metrics
Experience functioning as a team member, providing support to reach a common goal
Minimum home internet speed of 25 Mbps download and 10 Mbps upload
Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information

Benefits

Comp & perks

Paid time off
401(k) retirement savings plan
Employee assistance program
Business travel and accident benefits
Internet expense payment for employees who live and work from home in California, Illinois, Montana, or South Dakota
Telephone equipment appropriate to meet business requirements
Remote work arrangement
Flexible/variable weekly hours